Well Therapy Client Questionnaire

Please complete this questionnaire as fully as possible. If you need additional space, please use the bottom of the form.

Today's Date

YYYY

Name of Client

First Name

Last Name

Date of Birth

YYYY

Age

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Referred By

Occupation

Employer

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Religious Affiliation

Recreation (some typical activities)

Marital status

Marital Status Details

Please state the reason for which you are seeking treatment.

When and how did the issues(s) begin and what have you done to help yourself?

Please list each person who resides with you (please indicate name/relationship/age)

Do you have children who do not live with you?

If YES, please provide name(s) and ages()

Have there been deaths in your family or among your friends?

If YES, please list (who/when)

Have you moved recently?

If YES, when?

YYYY

Have you moved often?

If YES, please explain

Do you plan a move in the near future?

If YES, please explain